Sunday, May 8, 2016

Wrist Pain in Baseball

Baseball season is upon us and, unfortunately, that means that baseball- related injuries are also around the corner.  Pain on the pinky- side of the wrist without a clear trauma leads us to think about 3 primary diagnoses.  Each of these can cause the player to miss significant time and, therefore, an early diagnosis is key to allow treatment and return to play.  And unfortunately, prevention of any of these 3 is difficult or impossible.  I have previous posted on Wrist Sprains; the 3 diagnoses on this post can also be considered in patients with a wrist sprain.

1) Hook of the hamate fracture.  The hamate bone is on the pinky side of the wrist and can cause pain and ultimately can break in any racquet or stick sport.  Baseball players are most at risk.  We believe that the pressure from the baseball bat exerts a force on this unusually shaped bone. Over time, pain can develop but initially it might be minor for some patients.  But once the bone breaks, more significant pain develops.  If not treated over months or years, other problems can develop related to nearby structures including flexor tendons and the ulnar nerve.

There are few reasonable treatment options for a hook of the hamate fracture.  While casting can be considered, healing of the bone is unpredictable.  Therefore, for most players, this small piece of bone is simply removed.  Surgery is generally safe and return to play can be as soon as 6-8 weeks although in some players, it will take longer.

The blue arrow points to the location of the hook of the hamate and this is also the most common site of pain.
2) Another cause of pain on the pinky side of the wrist in baseball players (along with many others) is an injury to the TFCC.  The TFCC stands for triangular fibrocartilage complex and is similar to the meniscus in the knee- it provides padding between the bones.  A severe twisting injury or repetitive twisting over time can lead to the injury of this structure.  It may begin as a irritant but can become severe and prevent activities.

Treatment of TFCC injuries begins with anti inflammatory medication and immobilization.  Ideally a cast or rigid splint is worn for 6 weeks in an attempt to calm the wrist pain.  If the player is unwilling to 'shut it down' there are other types of splints that can be worn, including a wrist widget.  A failure to improve may lead to consideration of a steroid injection and, on occasion, wrist arthroscopy for a clean- up procedure or repair.  

3) The 3rd common cause of pain on the pinky side of the wrist in baseball players is tendonitis of the extensor carpi ulnaris (ECU tendon).  This typically begins with minor pain that can extend up and down the forearm. Over time, it can become sharp pain.  The pain is often worse with certain wrist motions (extension, ulnar deviation, rotation).  Rarely, with a sharp twisting injury, the tendon can slide out of its groove and pop in and out of place.  This is a more severe injury.

Treatment also begins with anti inflammatory medications and rest.  A hard cast or splint is ideal but, again, the wrist widget type of splint can also be helpful.  Rarely a steroid injection may be necessary or even less commonly, surgery may be required.

The red arrow points to the typically location of ECU tendonitis.  The blue area points to the area of pain with a TFCC injury.

The red arrow points to the typically location of ECU tendonitis.  The  ECU tendon stands out. The blue area points to the area of pain with a TFCC injury.
Charles A. Goldfarb, MD
My Bio at Washington University


  1. My 16 year old son was diagnosed with an ECU subluxation. 4wks in long arm cast, 2wks in short, 2wks in soft cast, 4 weeks doing nothing. No pt or OT was ordered. The dr then told him he could swing and hit. On the 5th swing, he experienced the same pain. No pain or swelling after. The tendon subluxes only when he really turns his wrist (which he has to for hitting) and he says it hurts a bit..He is convinced he needs surgery. The dr says just rest for 1 more month and do strengthening exercises on your own. No MRI was ordered. Any advice??

    1. Thank you for your question. I agree with the treatment so far as some patients will respond and the tendon will become stable. 12 weeks is a good period of rest. However, at this point, it might not resolve on its own. Therapy could be helpful but if the tendon is still slipping out of position, it is tough to imagine that it stabilize now. I agree that ultrasound or MRI could provide additional information that might be helpful.
      So, while avoiding surgery is the best course, sometimes it is not successful. Good luck!